Provider Demographics
NPI:1043935364
Name:MORENO, AMY JOCELYN
Entity Type:Individual
Prefix:MISS
First Name:AMY
Middle Name:JOCELYN
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 GIRALDA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-5303
Mailing Address - Country:US
Mailing Address - Phone:305-219-5724
Mailing Address - Fax:
Practice Address - Street 1:530 NW 43RD CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5408
Practice Address - Country:US
Practice Address - Phone:305-219-5724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF10220758363LF0000X
FL669721390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily